SAPPro.pdf

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ULTRASOUND-GUIDANCE ALLOWS THE

PERFORMANCE OF PERIPHERAL NERVE BLOCKS

UNDER GENERAL ANESTHESIA

Meg A. Rosenblatt M.D.

Professor of Anesthesiology and Orthopaedics

Mount Sinai School of Medicine
http://www.providianmedical.com/files/imagecache/preview/product_guide_mturbo.jpg


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Minerva . 2010;76:645.


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47 yo, 122kg for TSA Huntingtons disease, hypothyroidism, depression

Continuous active choreiform movements

Alprazolam, citalopram, levothyroxine, ramelteon

Intractable shoulder pain Surgeons reluctant to perform procedure

Athetosis would disrupt arthroplasty

Discussions with:

Patient

Family

Surgeon


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GETA Midazolam, fentanyl

RSI and endotracheal intubation Propofol and rocuronium

US-guided continuous ISB In-plane

17 gauge Tuohy needle

Between C5 and C6

20 mL 1.5% mepivacaine + 20 mL 0.5% bupivacaine

Catheter inserted/secured 6 cm from skin

Post-op Bupivacaine 0.1%, 8mL/hr

48 hours


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Retrospective analysis of ISB under GA

548 pts for arthroscopic shoulder surgery

GA via LMA

22-gauge 50 mm stimulating needle

0.4-0.5 mA

Bupivacaine 0.5% 20 mL or ropivacaine 0.75% 30 mL

24 hours in hospital

Assessed 4-8 weeks after surgery

0% long-term sequelae

Bogdanov. EJA. 2005;22:107.


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Prospective analysis of ISB under GA

910 pts

22-gauge needle, nerve stimulator


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Results

Success rates and

complications of ISBafter GA are similar to

results in awake pts

Short-term = 4.4%

Long-term = 0.8%

Misamore. J Shoulder Elbow Surg 2011;20:308.


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Prospective look at complications 98.6% follow-up/2-4 wks post procedure

New neurologic complications

56/690 (8.2%) at day 10

37/1000 (3.7%) at 1 month

6/1000 (0.6%) at 6 months

Fredrickson. Anaesth 2009;64:836.


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Fredrickson. Anaesth 2009;64:836.


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French Language Society of Pediatric

Anesthesiologists (ADARPEF)

1-year prospective, multi-center study

Look at epidemiology and morbidity of RA in children

47 institutions

104,612 only GA 29, 970 RA with GA

1,262 only RA

RA

34% central blocks 66% peripheral blocks 29% upper/lower extremity

71% trunk/face

Ecoffey. Ped Anesth 2010;20:1061.


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Findings

175 complications

112 (64% central blocks)

134 deemed inappropriate

Positive test dose, blood through needles/catheters,incomplete blocks, urinary retention

41 in 40 patientsMost occurred in operating room

No sequelae after 1 year

Confirmed low complication rate

96% performed with GA or heavy sedation



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Why is this a debate?
http://www.google.com/imgres?imgurl=http://www.conversantlife.com/files/imagecache/blog_wizard/files/blog_wizard/Debate.jpg&imgrefurl=http://www.conversantlife.com/morality/upcoming-debate-on-god-and-morality&usg=__XFFlDuMER-PDZql8DfXGZ_01YSM=&h=241&w=280&sz=18&hl=en&start=2&sig2=l2o1ze8425_JC5SxCXCc4w&zoom=0&itbs=1&tbnid=3dDAjdz4bKasAM:&tbnh=98&tbnw=114&prev=/images?q=debate&hl=en&gbv=2&tbs=isch:1&ei=IeZKTbSGJsK_gQe7kcDnDw


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Anesthesiology 2000;93:1541.


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Benumofs conclusions:

1. GA is a relative contraindication for ISB

2. Needles >1.0-1.25 inches should not be used

3. Ensure the patient does not unexpectedly move

4. The ISB needle should have a caudad direction

5. Obese patients have obscure landmarks

Anesthesiology 2000;93:1541.


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If patients are asleep

Lose warning signs of local anesthetic

toxicity (LAST)

Cant report pain from errant needleplacement


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GA is protective

Benzodiazepines, barbiturates, propofol,

vapors, threshold for LA-inducedseizures

Decreases incidence of LAST?

T d l bl h


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Stricker.

Anesthesiology2011;114:431.

Test dose more reliable than patient

reports of symptoms


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US decreases LA doses

Minimumvolume for

ISB=3.6 mL

Renes. RAPM 2010;35:529.


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If patients are asleep

Lose warning signs of local anesthetic

toxicity (LAST)

Cant report pain from errant needle

placement


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Barrington. RAPM 2009;34:534.


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PATIENTS CANNOT RELIABLY TELLIF A NEEDLE IS INTRANEURAL!

And we know it frequently is


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24 pts for popliteal block

Stimulation .2


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Cant reliably elicit a paresthesia!

102 patients

Needle-nerve contact

Confirmed by US

Paresthesias

True positives-39

False negatives-63 38.2% sensitive

Perlas. RAPM 2006;31:445.


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With US we are MINIMIZINGneural trauma

Think what we have been doing!


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Regional with GA

Decreases the chance of sudden movements

Increases patient acceptance

Increases number of patients who will benefit from

the intervention

Pediatric patients

Dementia

Developmental delay


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Is there a really a difference between:

General anesthesia

MAC with

Midazolam

Fentanyl

Remifentanil

Propofol

Dexmedetomidine

ASRA P i Ad i N l i


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ASRA Practice Advisory on Neurologic

Complications in RA and Pain Medicine

October 2008

ISB should NOT be placed in any anesthetized patient

US-guided blocks/pressure monitoring new

Recommendations may change with: Data

Experience

Over 1000 indexed publications since advisory!

Divergent recommendations regarding PNBs Unsafe in adults

Acceptable in children

RAPM 2008;33:404-15.


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Ultrasound guidance

Decreases risk of intravascular injection

Allows decreased volumes of agents

Decreasing risk of LAST?

Continuous visualization can prevent catastrophic

events

Avoid intra-spinal cord injections

US blocks different from NS/paresthesia


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Lateral Medial


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Conclusions

We have been

deluding

ourselves thing

that keeping

patients awake

will prevent

neurologiccomplications

Meticulous attention to technique to

prevent complications

US-guidance is the most successfulmethod of nerve localization

The combination of US and technique

permits the performance of RA withGA

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